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R61rTLER-RYA.Y INC. GR Job# 1820- 0072 <br /> SWRCB,January 2006 <br /> Spill Bucket Testing Report Form <br /> This form is intended for use by contractors performing annual testing of UST spill containment structures. The Completed form and <br /> Printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1.FACILITY INFORMATION <br /> acility Name: Arco 6080 Date of Testing: 1/29/2018 <br /> 'acility Address: 85 E. Louise Ave Lathrop 95330 <br /> acility Contact: Daryl Lee Phone: 415-902-5089 <br /> ate Local Agency Was Notified of Testing: <br /> ameofLocal gency Inspector i present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court,Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: David Rouse <br /> Credentials:(1) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other(Specify) <br /> License Number: 220793 ICC Tech Number: 8 2 9 2 5 3 0 <br /> 3.SPILL BUCKET TESTING INFORMATION <br /> Test Method Used: Hydrostatic Vacuum Other <br /> Test Equipment Used: Standard Tape Measurer Equipment Resolution: 1/16" <br /> Identify Spill Bucket(By Tank 1 2 3 <br /> Number,Stored Product,etc. 87 Fill 91 Fill DSL Fill 4 87 Fill <br /> [Final <br /> ucket Installation Type: irect Bury irect Bury irect Bury irect Bury <br /> Contained in Sump 21contained in Sump E)Contained in Sump Contained in Sump <br /> cket Diameter: 1211 12" 12" 1211 <br /> cket Depth: 1411 1411 14" 1411 <br /> ait time between applying <br /> cuum/waterand Start oftest: 5 min 5 min 5 min 5 min <br /> st Start Time(Ti): 9 :4 5 9 :45 9:45 9:4 5 <br /> tial Reading(Ri): 1211 12" 12" 1211 <br /> st End Time(TO: 10 :45 10 :4 5 10:45 10 :45 <br /> Reading(Rf) 1211 1211 12" 1211 <br /> Test duration(Tf-Ti): 1 Hr 1 Hr 1 Hr 1 Hr <br /> Change in Reading(Rf-Ri): 0 0 0 0 <br /> Pass/Fail Threshold or Criteria: 0 0 0 0 <br /> Test Resolta: ass OFeil oPass Fail Psss Fall ElPaw Fait <br /> Comments-(include information on repairs made prior to testing,and recommended follow-up for failed tests) <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> I hereby certify that all the information conlained in t is report is true,accurate,and in full compliance with legal requirements <br /> Technician's Signature: Date: 1/29/2018 <br /> (1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br /> may be more stringent. <br />